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Oral Medicine and Pathology Dental and periodontal status in a group of oncological patients

Clinical evaluation of dental and periodontal status in a group of


oncological patients before chemotherapy

Mnica Paula Lpez Galindo 1, Jos V. Bagn 2, Yolanda Jimnez Soriano 3, Francisco Alpiste 4, Carlos Camps 5

(1) Dentist. University of Valencia.


(2) Chairman of Oral Medicine, Valencia University Medical and Dental School. Head of the Service of Odontology, Valencia University
General Hospital.
(3) Associate Professor of Oral Medicine, Valencia University Medical and Dental School.Valencia
(4) Associate Professor of Periodontology, Valencia University.
(5) Head of the Service of Oncology, Valencia University General Hospital. (Spain)

Correspondence:
Dr. Jos Vicente Bagn Sebastin
Lpez-Galindo MP, Bagn JV, Jimnez-Soriano Y, Alpiste F, Camps C.
Hospital General Universitario de Valencia
Clinical evaluation of dental and periodontal status in a group of oncologi-
Servicio de Estomatologa
cal patients before chemotherapy. Med Oral Patol Oral Cir Bucal 2006;11:
Av/ Tres Cruces s/n
E17-21.
46.014 Valencia Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698- 6946
E-mail: bagan@uv.es

Click here to view the


Received: 25-01-2005
Accepted: 4-12-2005
article in Spanish

Indexed in:
-Index Medicus / MEDLINE / PubMed
-EMBASE, Excerpta Medica
-Indice Mdico Espaol
-IBECS

ABSTRACT
Objective: To evaluate the dental status of 88 cancer patients before chemotherapy.
Material and methods: Eighty-eight patients with cancer in different body locations were studied and compared with a control
group. Dental plaque was assessed by means of the Silness and Le index, dental status with the DMFT index, and periodontal
status with the modified CPI index.
Results: In the oncological patients the mean Silness and Le index was 1.280.11. Patients showed multiple missing teeth (mean
number 7.550.80); the mean number of decayed teeth was 2.100.36; and the mean number of filled teeth was 2.270.37.
As to periodontal status, the mean modified CPI index was 1.450.11.
In the control group, the mean Silness and Le index was 0.940.00. The mean number of decayed teeth was 1.210.25; the
mean number of missing teeth was 4.970.67; and the mean number of filled teeth was 4.820.44. The mean modified CPI
index was 1.290.10.
Conclusions: Oncological patients in our study showed more dental plaque versus healthy patients and more decayed and
missing teeth. However, patients in the control group showed more filled teeth than cancer patients. Periodontal status as de-
termined by the modified CPI index was similar in both patient groups.

Key words: Chemotherapy, dental and periodontal status.

RESUMEN
Objetivos: Valorar el estado bucodental en 88 pacientes con cnceres corporales, previo al inicio de su tratamiento quimioterpico.
Diseo del estudio: Estudiamos 88 pacientes con cnceres de diferentes localizaciones corporales y los comparamos con un
grupo control. Analizamos la placa dental (mediante el ndice de Silness y Le), el estado dental (mediante el ndice CAO.D)
y el estado periodontal (ndice CPI modificado).
Resultados: En el grupo de pacientes oncolgicos, la media del ndice de placa de Silnness y Le fue de 1,280,11. Los
pacientes presentaban mltiples ausencias dentarias, siendo la media de dientes ausentes por caries de 7,550,80. Tambin
se observ que la media de caries por paciente era de 2,100,36 y de dientes obturados de 2,270,37; por lo que respecta al
estado periodontal, el valor del ndice CPI modificado fue de 1,450,11.
En el grupo control, la media del ndice de placa de Silnness y Le fue de 0,940,00. Por lo que respecta a los dientes caria-
dos, la media era de 1,210,25; la media de dientes ausentes por caries era de 4,970,67 y el valor de la media de los dientes

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Medicina Oral S.L. Email: medicina@medicinaoral.com
Med Oral Patol Oral Cir Bucal 2006;11:E17-21. Dental and periodontal status in a group of oncological patients

obturados era de 4,820,44. La media del ndice periodontal CPI modificado, en el grupo control, fue de 1,290,10.
Conclusiones: Los pacientes oncolgicos de nuestro estudio presentaron mayor cantidad de placa dental que los pacientes
sanos. Adems tenan ms dientes cariados y ausentes que los individuos sanos. En cambio, los pacientes del grupo control
presentaron ms dientes obturados que los pacientes afectos de cncer. El estado periodontal estudiado en ambos grupos de
pacientes, mediante el ndice CPI modificado, demostr que era similar en los individuos sanos y en los oncolgicos.

Palabras clave: Quimioterapia, estado dental y periodontal.

INTRODUCTION criteria: absence of systemic disorders; absence of medication


Antineoplastic therapy includes surgery, radiotherapy and che- of any kind at the time of the study.
motherapy alone or in combination, depending on the nature There were no significant differences between the two groups
and extent of the tumor (1). in terms of age and sex. Mean age in the control group was
Antineoplastic chemotherapy presently consists of the use of 55.51 years (SD = 15.18). There were 41 males (45.6%) and
drugs (cytostatic agents) that destroy or hinder the proliferation 49 females (54.4%).
of tumor cells. Treatment is followed by tumor cell necrosis, After compiling the clinical history, the following explorations
after which a neoplastic cell recovery phase may be observed. were performed in both groups:
The problem of these treatments is that in most cases their ac- (a) Evaluation of dental plaque. Buccal and lingual/palatal
tion is not selectively target to tumor cells. In effect, anticancer examination of the dental arches was performed with a plane
drugs affect not only neoplastic cells but also other similarly mouth mirror (number 5) and a dental probe (number 23).
rapidly dividing normal cells such as bone marrow, hair folli- Dental plaque was assessed in the following teeth: 1.6, 1.1,
cle cells and the orodigestive epithelium (2). Chemotherapy 2.4, 3.6, 3.1 and 4.6, according to the Silness and Le scale
is characterized by a narrow borderline between its antitumor (4). After the teeth were examined, the arithmetic mean was
effects and toxicity (which may even prove fatal) (3). Due to calculated for all scores obtained in each patient.
the side effects upon the oral cavity, patient oral status prior (b) Evaluation of the DMFT index (4). Using a plane mouth mi-
to chemotherapy is important for the quality of life of these rror (number 5) and a dental probe (number 23), we recorded the
patients, because the possibilities for intervention after che- number of decayed (D), missing (M) and filled (F) permanent
motherapy are limited. teeth. The sum of these three values yielded the corresponding
The present study explores oral and dental status in a group of DMFT index (T = permanent teeth). The caries criteria used
patients with cancer before chemotherapy, with the evaluation were those of the World Health Organization (WHO), which
of possible prior dental intervention, taking into account aspects defines caries when ... a lesion in a pit or fissure, or on a
such as tumor stage and location, and patient dental hygiene smooth tooth surface, has an unmistakable cavity, undetermined
and motivation. enamel, or a detectably softened floor or wall (5). A crown
was considered filled, with decay, when it had one or more
MATERIAL AND METHODS permanent restorations and one or more areas that were seen to
Oral and dental status was explored in 88 patients in the Service be decayed. Third molars were excluded from the study.
of Odontology (Valencia University General Hospital; Valencia, (c) Evaluation of the modified Community Periodontal Index
Spain), between October 2000 and January 2004. (modified CPI)(4,6-8). Instead of dividing the mouth into
Inclusion criteria were: sextants, we took the following tooth numbers: 1.7 or 1.6, 1.1,
1. A diagnosis of cancer in any location, except oral cancer. 2.6 or 2.7, 3.6 or 3.7, 3.1 and 4.6 or 4.7. Periodontal probing
2. Patients programmed for systemic chemotherapy. was carried out with a plane mouth mirror (number 5) and
3. Presence of teeth to allow the evaluation of dental and a dental probe. Each tooth was examined in the buccal and
periodontal status. Edentulous patients were excluded from lingual/palatal surfaces at three points (mesial, medial and
the study. distal); the greatest probe depth was registered in mm. The
The mean patient age was 56.75 years (standard deviation (SD) mean value of the pocket depth was obtained by calculating the
= 14.16 years). There were 38 males (43.2%) and 50 females arithmetic mean of the greatest values obtained in the explored
(56.8%). The patients were examined in the mentioned Ser- teeth. Periodontal status was scored as follows: 0 = health; 1 =
vice of Odontology prior to chemotherapy. A clinical history bleeding; 2 = supra- or subgingival calculus, excessive fillings;
was compiled, and certain data were recorded, such as: toxic 3 = pocket depth 4-5 mm; 4 = pocket depth 6 mm or more; X
habits (smoking, alcohol abuse) and tumor diagnosis, location = excluded sextant.
and stage. Depending on their oral hygiene status, the patients The data obtained were subjected to descriptive and com-
were classified into three groups: excellent oral hygiene (tooth parative statistical analysis. The Student t-test was used for
brushing 3 times a day); good oral hygiene (brushing 1-2 times comparing the means of quantitative variables, while analysis
a day); poor oral hygiene (failure to brush daily). of variance (ANOVA) was performed to compare the means
To conduct a comparative study versus healthy individuals, of more than two groups of quantitative variables. Statistical
90 controls were included, based on the following inclusion significance was considered for p 0.05.

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Oral Medicine and Pathology Dental and periodontal status in a group of oncological patients

RESULTS Table 1. Number and percentage of patients, according to tumor diagnosis in


the oncological group.
Thirty-six patients (40.9%) were diagnosed with adenocarci-
noma, 22 (25.0%) with infiltrating ductal carcinoma, 8 (9.1%) Diagnosis No. of cases %
squamous cell carcinoma, and 22 patients (25.0%) with some
other type of cancer (Table 1). Adenocarcinoma 36 40.9
The distribution of tumor location was as follows: 27 patients Ductal infiltrating 22 25.0
(30.7%) had intestinal cancer, 26 (29.5%) had breast cancer, carcinoma
12 patients (13.6%) had lung cancer, and 23 (26.1%) presented
Squamous cell carcinoma 8 9.1
multiple locations (Table 2).
Tumor staging according to the TNM classification showed Others 22 25.0
13 patients (14.8%) to be in stage I, 19 (21.6%) in stage II, 22
(25.0%) in stage III, and 34 (38.6%) in stage IV. The data rela-
ting to oral hygiene on both groups are reported in Table 3.
The results relating to dental and periodontal evaluation (inclu-
ding plaque index, mean carious decayed and filled teeth, DMFT
index and modified CPI index) are described in Table 4.
Table 3. Oral hygiene in both groups of patients (oncological and control),
Table 2. Number and percentage of patients, according to tumor location with corresponding statistical significance.
in the oncological group.

Tumor location No. of cases % Oncological


Oral hygiene Controls (n, %)
patients (n, %)
Intestine 27 30.7

Breast 26 29.5 Excellent 8 (9.1 %) 16 (17.8 %)

Lung 12 13.6 Good 60 (68.2 %) 71 (78.9 %)

Others 23 26.1 Poor 20 (22.7 %) 3 (3.3 %)

Table 4. Mean, standard deviation and statistical significance in both groups of patients.

Oncological patients Controls (n = 90) Significance


(n = 88) (meanSD)
(meanSD)

Silness and Le plaque 1.280.97 0.940.79 t=2.58


index p=0.01

Carious teeth 2.063.36 1.212.37 t=1.95


p=0.05

Decayed teeth 7.557.52 4.976.34 t=2.48


p=0.01

Filled teeth 2.273.48 4.824.22 t=-4.39


p=0.00

DMFT index 11.898.26 10.976.74 t=0.81


p=0.42

Modified CPI index 1.451.04 1.290.98 t=1.08


p=0.28

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Med Oral Patol Oral Cir Bucal 2006;11:E17-21. Dental and periodontal status in a group of oncological patients

DISCUSSION possible foci of dental disease with the aim of minimizing or


While chemotherapy offers important positive results in the eradicating the effects of chemotherapy upon the oral cavity
management of cancer, it also has a series of undesirable effects. (21-33). Moderate dental plaque levels may contribute to local
In this context, the creation of healthy oral conditions before infection in immunocompromised patients (18).
chemotherapy is administered can afford patient benefits, since Trauma-inducing prostheses, and sharp-edged or broken teeth
the negative effects of chemotherapy upon the oral cavity are imply an increased risk of ulcerations and mucositis (34). Hence
less pronounced in the presence of a healthy mouth without the importance of correcting these possible alterations before
dental or periodontal disorders (4,9-12). chemotherapy is administered.
To assess oral hygiene, the Silness and Le index was measured In conclusion, our oncological patients showed more dental
yielding a mean score of 1.280.11 in the 88 oncological plaque, and more decayed and missing teeth than the controls.
patients, and 0.940.00 in the control group. The only study However, no differences in modified CPI periodontal index
similar to our own found in the literature was published by were observed between the two groups.
Jankovic et al. (13). In this study, 20 healthy patients were com-
pared with 30 oncological patients before the administration REFERENCES
of chemotherapy; in both groups the age and sex distributions 1. Feliu J, Artal A, Garrido P. Tratamientos oncolgicos. En: Ordez A,
Garca de Paredes ML, Feliu J, Zamora P, eds. Oncologa clnica. Madrid:
were similar to our own. Based on the Silness and Le index,
Interamericana McGraw-Hill; 1992. p. 261-5.
the authors recorded a value of 1.390.65 in the 20 healthy 2. Oate RE, Bermejo A. Asistencia odontolgica a pacientes oncolgicos. En:
subjects and 1.570.90 in the 30 oncological patients. The Bulln P, Machuca G, eds. La atencin odontolgica en pacientes mdicamente
study failed to mention whether the intergroup differences were comprometidos. Madrid: Laboratorios Normon; 1996. p. 387-414.
3. Holmes S. The oral complications of specific anticancer therapy. Int J Nurs
statistically significant, however. The values recorded in both
Stud 1991;28:343-60.
groups were slightly greater than our own. 4. Cuenca E. La identificacin de problemas en Odontologa Comunitaria.
Our study reflects a high DMFT index in the oncological group, En: Cuenca E., Manau C, Serra LL eds. Manual de Odontologa Preventiva y
with a mean value of 11.890.88. The magnitude of this score Comunitaria. Barcelona: Ed. Masson, S.A. 1991. p. 226-42.
5. WHO.Oral Health Surveis Basic Methos. 2 Edition. World Health Orga-
was not due to the decayed (mean 2.100.36) or filled teeth
nization. Geneva, 1977.
(mean 2.270.37), but to the missing teeth (mean 7.550.80). 6. Ainamo J. Epidemiologa de la enfermedad periodontal. En: Lindhe J ed.
The mean DMFT score for the control group was 10.970.71, Periodontologa Clnica. Buenos Aires: Editorial Mdica Panamericana;
and was largely attributable to missing and filled teeth. 1989. p. 70-86.
7. Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. De-
In a study of 736 healthy adults aged between 19-64 years,
velopment of the World Health Organization (WHO) Community Periodontal
Athanassouli et al (14) in 1990 reported a DMFT index of Index of Treatment Needs (CPITN). Int Dent J 1982;32:281-91.
8.995.98 for the 19-24 years age interval, versus 17.056.58 8. Cutress T., Ainamo J., Sardo-Infirri J. The Community Periodontal Index
for the 55-64 years interval. These values are slightly greater of Treatment Needs (CPITN) procedure for population groups and individual.
Int Dent J 1987;37:223-33.
than our own.
9. Milin MA, Silvestre J, Jimnez Y. Patologa infecciosa oral en enfermos con
As regards periodontal status assessed by the modified CPI procesos sistmicos. En: Libana J, Bagn JV eds. Teraputica antimicrobiana
index, the mean value was found to be higher among the on- en odontoestomatologa. Madrid: IM & C; 1996. p. 369-82.
cological patients (mean 1.450.11) than in the healthy group 10. Toht BB, Martin JW, Fleming TJ. Complicaciones orales asociadas a la
terapia oncolgica. La experiencia del Centro Oncolgico MD Anderson. Arch
(mean 1.290.10) though the difference failed to reach sta-
Odontoestomatol 1991;7: 87-96.
tistical significance (t=1.08; p=0.28). 11. Lockhart PB, Clark J. Pretherapy dental status of patients with malignant con-
Diamanti-Kipioti et al. (15), in 169 healthy Athenian farmers ditions of the head and neck. Oral Surg Oral Med Oral Pathol 1994;76:236-41.
aged 25-64 years, found the CPITN (Community Periodontal 12. Scully C, Epstein JB. Oral health care for the cancer patient. Oral Oncol
Eur J Cancer 1996;23B:281-92.
Index of Treatment Needs) to be 11.4 (i.e., similar to the score
13. Jankovic L, Jelic S, Filipovic-Ljeskovic I, Ristovic. Salivary immunog-
recorded in our groups of patients). lobulins in cancer patients with chemotherapy-related oral mucosa damage.
On relating different parameters to periodontal status, statistica- Oral Oncol, Eur J Cancer 1995;31B: 160-5.
lly significant correlations were observed. In effect, a positive 14. Athanassouli T, Koletsi-Kounari H, Mamai-Homata H, Panagopoulos H.
Oral health status of adult population in Athens, greece. Community Dent
relation was found between the Silness and Le plaque index
Oral Epidemiol 1990;17:82-4.
and the modified CPI periodontal index (R=0.55; p=0.00), i.e., 15. Diamanti-Kipioti A, Papapanou PN, Moraitaki-Tsami A, Lindhe J, Mitsis
the higher the plaque index, the higher the periodontal index. F. Comparative estimation of periodontal conditions by means of different
The presence of dental plaque is related to poorer periodontal index systems. J Clin Periodontol 1993;20:656-61.
16. Baca P, Llodra JC, Bravo M. Caries dental. Etiopatogenia. Clnica. Diag-
status (16,17).
nstico. Control y tratamiento. En: Teraputica antimicrobiana en Odontoes-
A positive relationship was found between carious teeth and tomatologa. Madrid: IM&C, 1996. p. 219-32.
the modified CPI index (R=0.24; p=0.03). 17. Martnez P. Enfermedad periodontal. En: Bagn JV, Ceballos A, Bermejo
Patients initially presenting a poor periodontal and/or carious et al. Medicina Oral. 1 ed. Barcelona: Masson SA, 1995. p. 103-17.
18. DePaola LG, Minah GE, Peterson DE, Williams LT, Overholser CD,
status who are treated before chemotherapy and receive in-
Stansbury DM et al. Dental care for patiens receiving chemotherapy. JADA
tense oral care during treatment show a significant reduction 1986;112:198-203.
in the frequency of the oral complications associated with 19. Guggenheimer J, Verbin RS, Appel BN, Schmitz J. Clinicopathologic
chemotherapy (18-20). Many authors consider it necessary to effects of cancer chemotherapeutic agents on human buccal mucosa. Oral
Surg 1977;44:58-63.
provide dental treatment before chemotherapy, eliminating any
20. Lockart PB, Sonis ST. Alterations in the oral mucosa caused by chemo-

E20
Oral Medicine and Pathology Dental and periodontal status in a group of oncological patients

therapeutic agents. J Dermatol Surg Oncol 1981;7:1019-25.


21. Laine PO, Lindquist JC, Pyrhnen SO, Strand-Pettinen M, Teerenhovi LM,
Meurman JH. Oral infection as a reason for febrile episodes in lymphoma pa-
tients receiving cytostatic drugs. Oral Oncol, Eur J Cancer 1992;28B:103-7.
22. Bagn Sebastin JV, Pearrocha Diago M. Patologa oral inducida por
frmacos y sustancias qumicas. En: Esplugues J, Morcillo EJ, de Andrs-
Trelles F, eds. Farmacologa en clnica dental. Barcelona: J. R. Prous Editores;
1993. p. 438-9.
23. Rutkauskas JS, Davis JW. Effects of chlorhexidine during immunosuppres-
sive chemotherapy. Oral Surg Oral Med Oral Pathol 1993;76:441-8.
24. Graham KM, Pecoraro DA, Ventura M, Meyer CC. Reducing the incidence
of stomatitis using a quality assesment and improvement approach. Cancer
Nurs 1993;16:117-22.
25. Lindquist SF, Hickey AJ, Drane JB. Effect of oral hygiene on stomatitis in
patients receiving cancer chemotherapy J Prosthet Dent 1978;40:312-4.
26. Heimdal A, Mattson T, Dahlf G, Lnnquist B, Ringden O. The oral cavity
as a port of entry for early infections in patients treated with bone marrow
transplantation. Oral Surg Oral Med Oral Pathol 1989;68:711-6.
27. National Institutes of Health. National institutes of health consensus
development conference statement: oral complications of cancer therapies:
diagnosis, prevention and treatment. JADA 1989;119:179-83.
28. Hickey AJ, Toth BB, Lindquist SB. Effect of intravenous hyperalimentation
and oral care on the developement of oral stomatitis during cancer chemothe-
rapy. J Prosthet Dent 1982; 47:188-93.
29. Carl W, Higby DJ. Oral manifestations of bone marrow transplantation.
Am J Clin Oncol 1985;8:81-7.
30. hrn KO, Wahlin YB, Sjdn PO, Wahlin ACE. Indications for and re-
ferrals to oral care for cancer patients in a county hospital. Acta Oncolgica
1996;35:743-8.
31. Ellegard B, Bergman OJ, Ellegard J. Effect of plaque removal on patients
with acute leukemia. J Oral Pathol Med 1989;18:54-8.
32. Peterson DE, Overholser CD. Dental management of leukemic patients.
Oral Surg 1979;47:40-2.
33. Sonis S, Kunz A. Impact of improved dental services on the frequency
of oral complications of cancer therapy for patients with non-head-and-neck
malignancies. Oral Surg Oral Med Oral Pathol 1988;65:19-22.
34. Carl W. Local Radiation and systemic chemotherapy: preventing and
managing the oral complications. JADA 1993: 124:119-23.

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